transformer for aoma 4.8.18 nichols pm · people before newton and galileo had seen apples fall and...

Karen J. Nichols, DO, MA, MACOI, CSProfessor, Internal Medicine

Dean, Midwestern UniversityChicago College of Osteopathic Medicine

Past President, American Osteopathic AssociationPast President, Arizona Osteopathic Medical Association

©KarenNichols2018

No Disclosures

How Osteopathic Thought StartedWhere We Are Now Process Content

Where We Are And Can Go!!

Are you going to be the Transformee or the Transformer?

“roped his neck”“flung to the breeze the banner of osteopathy”Baker University

Baldwin City, Kansas“lunatic”

Methodist Church“heretic”

How Osteopathic Thought Started

New profession??


New profession?? No!


He thought “differently”He saw the world “differently”



“Let us not be governed today by what we did

yesterday, not tomorrow by what we do today, for day by day we must show progress.”


“He did not invent a system of healing. Like the force of gravity, osteopathy was always present, something familiar to everyone, waiting for a perceptive mind to unlock its secrets. ‘Millions of people before Newton and Galileo had seen apples fall and pendulums swing,’… but practically none of them taught the world what those simple and familiar phenomena meant. So it was with Dr. Still. Millions of people had seen the same things he had seen … but practically none before Dr. Still had ever learned to work with Nature and never against her in the healing art.”

John Lewis “A.T. Still, From Dry Bones to the Man”

UME (DO/MD) 1916 1970’s 2003

GME (DO/MD) 1940’s 1980’s 2003

How We Got Where We Are Now - Process

Where We Are Now - Process

AACOM/AOA/NMS data

DO Schools 34 schools 51 locations 32 states

Graduates, 2018 6644

OGME – 1 positions 2473

AAMC/NRMP dataMD Schools 147 schools

Graduates, 2018 18,818

PGY - 1 positions 30,232

More specific expectations Core Competencies Patient Care Medical Knowledge Practice-Based Learning and Improvement Systems-Based Practice Interpersonal and Communication Skills Professionalism Osteopathic Manipulative Medicine (on the DO side)

Separate competency AND embedded competency

“So what’s the problem?”

“So what’s the problem?”

% residents in specialties (2017)

USMD – 66.5% IMG – 22.9%DO – 10.6%

% residents in sub-specialties (2017)

USMD – 56.8% IMG – 35%DO – 7.7%

“…all in, or all out”

The Single Accreditation System

USMD graduates - 18,818

DO graduates -6,644

Total US Applicants =25,462

Why we have the single accreditation system

ACGME-accredited Year I positions in NRMP (MD) match – 30,232

AOA-accredited Year I positions in NMS (DO) match

2,473Total Positions = 32,705

USMD graduates - 18,818US-citizen IMGs - 5,075Non-US-citizen IMGs - 7,067

30,960

DO graduates - 6,644Total Applicants = 37,604

Why we have the single accreditation system

ACGME-accredited Year I positions in NRMP (MD) match

30,232

AOA-accredited Year I positions in NMS (DO) match

2,473Total Positions = 32,705

ACGME Category # %

Full Transition 1654 19%

Initial Accredited 3809 45%

Submitted 2031 24%

Applying 388 5%

Unsure 170 2%

Closed/Closing 493 6%

TOTAL 8545 100%

Current Status of Positions That Were Filled at Beginning of SAS

ACGME Category # %

Full Transition 1654 19%

Initial Accredited 3809 45%

Submitted 2031 24%

Applying 388 5%

Unsure 170 2%

Closed/Closing 493 6%

TOTAL 8545 100%

Current Status of Positions That Were Filled at Beginning of SAS

64%

KN1

KN1 Karen Nichols, 4/7/2018

Average: 44 AOA programs close annually (2005-2014)

112 closed in 2.5 years of SAS (186 positions) No trainees 63% Didn’t wish ACGME 14% Positions to other specialty 10% Closure previously planned 9% Other 4%

Closed Programs

DO

COCA

COMLEX

AOA

AOA-CME

AOA

GME Accreditation

Board Certification

Continuing Medical Education

Licensing Exam

College Accreditation

ACCME

USMLE

LCME

ABMS

ACGME

MD

Single Accreditation System

GME Accreditation

Board Certification

Continuing Medical Education

Licensing Exam

College Accreditation

Impact on Education Structure

Changed

GMEAccreditation

Unchanged

Board Certification

CME

Predoctoral Education

COMLEX

The agreement streamlines the accreditation of GME programs but preserves and protects the distinctive elements of the osteopathic medical education continuum.

17,800

DOs in GME Training

8,600 DOsAOA

9,200 DOs

ACGME

Single Accreditation System Embeds and Codifies Osteopathic Thought In Allopathic World

Osteopathically Focused 7.1.15 – 7.1.20 Apply and receive “pre-accreditation” designation

Where We Are Now - Process

Community-Based Education Primary Care Access Information AccessChanging Patient Demographics Exploding Medical KnowledgeCapturing Data

Where We Are Now - Content

Primary Care

AccessCommunity Based

Not enough physicians?Mal-distribution of physicians?

Primary Care Access

Patient-Centered Medical Home (outside in) Team-based coordination

Primary Care Delivery

Telemedicine Michigan Requires insurance companies to recognize TM claims Can’t require face-to-face encounter for billing

Accessed in: [email protected] July 12, 2012

Information Access

Changing Patient Demographics

Boomers - “Graduate,” not retire

“Not immortality, but resilience of youth with grow-back possibilities”

Verner Vinge, science fiction writer

Boomers Personal Touch

Gen XAdaptable

MillenialsWant to be Linked

“Study of the complete body of information”Genome All the DNA in the cell

Exploding Medical Knowledge “..omics”

Transcriptome RNA transcripts from genes or non-coding RNAs

Proteome All proteins that are translated Not 1:1 gene:protein

Metabolome All metabolites/cellular end products Is a metabolite pattern associated with a disease?

Epigenome Heritability not DNA sequence Environmental conditions that influence heritability thru

generations Mothers exposed to famine have specific imprinting on the side

chains of the ‘insulin growth factor 2’ gene 6 decades later

“-omics”

Microbiome The species of bacteria, fungi, viruses in each of

us Intestinal bacterial species More than 100X genes in human genome “Human stool has a data capacity of 100,000

terabytes of information stored per gram.”Larry Smarr, “The Measured Man,” The Atlantic, Jul/Aug 2012,pp.112-118.

“-omics”

ConnectomeComplete map of brain’s neuro-circuitryOur “selves” etched in wiring of our brainsMolded/remolded by life experienceHuman Connectome Project $38.5M NIH 2010-2015 Dyslexia Autism Alzheimer’s disease Schizophrenia

“-omics”

IndividualomeUnknome

“..omics”

165,000 health-related apps 6B of 7B people on Earth have mobile cell phone

subscriptionsNot inter-operable (2%)

Healthcare IT News, accessed 8.6.17

Capturing the Data

Be careful what “data” is captured!

“Personal Wearables”

Capturing the Data

Current Projects Skin Scan app Skin lesion photo Algorithm analysis

Breath analysis Detect lung cancer

AliveCor Smart car seat to detect arrhythmias

Capturing the Data

Capturing the Data

Capturing the Data

Crohn’s Cost of Care BCBS/IL $20K/patient

“Project Sonar” App for symptoms Bowel movements Abdominal pain Diarrhea drugs General wellbeing

Surveys every patient every monthAnnual disease-related hospital costs Decreased 64%

Overall cost of care Decreased 25%

Pre-emptive Monitoring

NASA Asthma Monitor

Twitter Data/Google Searches 500 million Tweets over 8 months Keywords track rates of influenza-related messages Forecast future influenza rates Entirely automated 90% correlation with CDC national health statistics

www.money.cnn.com

Predicting Illness

5,000,000 texts Peaks of data 8 pm – depression 11 pm – anxiety 4 am – self harm 5 am – substance abuse

Alice Gregory, “R U There? A new counseling service harnesses the power of the text message,” The New Yorker, February 9, 2015, pp. 30-35

“Crisis Text Line”

“Drowning in data; starving for wisdom”

E.O. Wilson

Capturing the Data

Creating “cyber-chondriacs”

“Data is not information. Information is not

knowledge. And knowledge is certainly not wisdom.”

H. Gilbert Welch, “Overdiagnosed: Making People Sick in the Pursuit of Health,” Beacon Press, 2011.

The future ain’t what it used to be!Yogi Berra

Where We Can Go!!

“If you don’t like change, you’re going to like

irrelevance even less.” Eric Shinseki (Retired), 34th Chief of Staff of the US Army Past Secretary, Veterans Administration, Washington, DC

“Change is good….. …..you go first.”

“Don’t let a crisis go to waste!”

Greater focus on chronic medical conditions (Continuum of care = “osteopathic!”)

Delivery of most care outside of hospitals Improving delivery of higher VALUE Higher quality Lower cost (price shopping)

Increased medical information and patient data Emanuel, E. “Reforming American Medical Education,” The

Milbank Quarterly, December 2017, Vol. 95, pp. 1-8.

“Four Trends in Medical Care”

Structure More Employed Physicians (New Tax Law!?)

Fewer Health Care Organizations Aetna/CVA Walmart/Humana Aurora/Advocate Ascension/Providence St. Joe Jefferson Health/Einstein ??

Aspects of Future Care

Our Future?

- - - - - - - -

Structure Risk-Based Payment Service Lines Less Specialty Delineation


Issues Health Care Disparities Population Health Erosion of fact-based medical information


Interprofessional Team-Based Practice

All administration automated Natural language interface with EMR Seamless patient data Organization Coordination Retrieval

Performance of professional tasks Enhanced diagnostic accuracy Personalized treatment plan Physician performing unique roles Non-routine Humanistic focus

What An Ideal System Might/Should Look Like…

“The skills we need most in today’s world – skills

like empathy, creativity, taking initiative and cross-disciplinary thinking – are all things that machines will never have.”

Tiffany Schlain Futurist, Emmy-nominated film-maker “Tomorrow Land” Smithsonian, April 2018,

p. 58

Pathogenesis to Salutogenesis Pathogenesis

Framework - American health care Study disease origins and causes Start with disease and work back

how to avoid manage/eliminate disease

Salutogenesis Study of health origins and causes How to create, enhance, improve

physical and mental and social wellbeing “What leads to better health?”

Craig M. Becker, PhD, Mary Alice Glascoff, EdD, W. Michael Felts, PhD, “Salutogenesis 30 years Later; Where do we go from here?” International Electronic Journal of Health Education, 2010;13:25-32.

What We Could Transform To

Salutogenic Orientation

Salutogenesis

Osteopathic = Salutogenic??

We have.. Medical knowledge Patient focused perspective Health emphasis

Moving toward… Delivery embedded in community Cost to Value Outcomes – based population health improvement

Transformee or Transformer?

PHYSICIANLEADERSHIP!

What is the “constant?”

If you follow > Transformee If you LEAD > TRANSFORMER

Not Degreed and Decreed Learned and Earned

Physician Leadership

Communication Emotional Intelligence Leading and Following Change Management Negotiations Conflict Management Critical Thinking Problem Solving Practice Improvement Clinical Informatics Population Health Creating and Managing Teams

Developing Tomorrow’s Physician Transformer Today

We see the world from a different perspective

“There are no osteopathic facts; there are medical facts seen through the osteopathic lens”

“To find health should be the object of the doctor.

Anyone can find disease.” Still AT. Philosophy of Osteopathy. Kirksville, MO: A.T. Still;

1899, p. 28.

The Future of Osteopathic Medicine?Back to the Future

Back to the Future

Back to the Future

iPad

Back to the Future

iPad

Fitbit!


yesterday, nor tomorrow by what we do today, for day by day, we must show progress.”1

“The determination of structure with a view to the discovery of function has been the foundation of progress.”2

"The keynote of progress ... is system and organization — in other words, 'team work.'"3

The Future of Osteopathic Medicine





Sir William Osler, MD Andrew Taylor Still, MD, DO Charles H. Mayo, MD






Andrew Taylor Still, MD, DO - 1 Sir William Osler, MD - 2 Charles H. Mayo, MD - 3

The Future of Medicine

We can do it!We are doing it! This approach to medical care is ours to lose!DOs are what America wants!!

The Future of Medicine

“To find health should be the object of the doctor.

Anyone can find disease.” Still AT. Philosophy of Osteopathy. Kirksville, MO: A.T. Still;

1899, p. 28.

We are the Transformers!!


Karen J. Nichols, DO, MA, MACOI, CSProfessor, Internal Medicine

Dean, Midwestern UniversityChicago College of Osteopathic Medicine

Past President, American Osteopathic AssociationPast President, Arizona Osteopathic Medical Association

©KarenNichols2018

transformer for aoma 4.8.18 nichols pm · people before newton and galileo had seen apples fall and...

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